Incomplete Discharge Documentation and ADL Records
Penalty
Summary
The facility failed to accurately document the discharge plan, disposition, and Activities of Daily Living (ADLs) for a resident who was readmitted with multiple diagnoses, including a subacute subdural hemorrhage, COPD, diabetes, repeated falls, and mobility issues. The resident's quarterly MDS assessment indicated an active discharge plan for return to the community, but the Discharge MDS later documented a planned discharge home with return not anticipated. The Discharge Summary form was incomplete, with several sections left blank, such as Skin Evaluation, Treatments, Cognitive/Psychosocial, ADLs/Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement. The Instructions After Discharge section was only partially completed, and there was no documentation of medication reconciliation, pharmacy details, or confirmation that medications or scripts were provided upon discharge. Additionally, there was no evidence that the Discharge Summary was given to or signed by the resident or staff. Review of the resident's physician orders and progress notes did not reveal any entries regarding discharge planning, education provided, or disposition of medications. Documentation of ADL tasks by CNAs was found to be incomplete, with multiple shifts showing blank entries for care provided. The DON confirmed that staff were expected to document care as close as possible to the time it was performed and acknowledged the incomplete and unsigned Discharge Summary. The facility's Medical Records policy required maintenance of records per federal requirements, which was not met in this instance.